Legislation alone can’t deliver NHS transformation
Transformation of NHS services outlined in the long-term plan require more than legislation to realise ambitions of integrated care. Social care, prevention, workforce and money are critical pieces of the puzzle.
NHS England and the Government are increasingly looking to legislation to drive the delivery of the Long-term plan’s ambitions. However, the risks NHS England evolves in isolation are increased unless reforms to social care, prevention and workforce are forthcoming. The NHS Long Term Plan has steadily unfolded in recent months, and its authors are clear legislation will accelerate integration. However, the scope and focus of this legislation will hinge on whether reforms are delivered. They include the long-awaited social care green paper, public health backing through the prevention green paper and the implementation of a workforce strategy.
Brexit and a shaky working majority are obvious challenges. However, the political sensitivity of rolling back on Andrew Lansley’s Health and Social Care Act 2012, which fundamentally changed the NHS, are not to be underestimated. The temptation therefore for limited legislation may be significant but removing competition barriers alone risks undermining the original ambition.
Broad consensus of a minimum requirement exists within NHS England/NHS Improvement leadership, but a good measuring stick for what else is needed from legislation could become clear when the new NHS Assembly holds its first meeting in the Spring.
There are legislative barriers to integration which need to be removed
In recent years both the Health and Social Care Committee (May 2018) and House of Lords NHS Sustainability Committee (February 2018) have highlighted where current legislation frustrated the transformation ambitions in the Five Year Forward View.
While the Health and Social Care Act turned NHS England into the most well-known quango in the UK, NHS leaders increasingly find the legislation an obstacle to long-term objectives. Indeed, the NHS Long Term Plan stated ambitions could be “generally achieved” within current frameworks but was clear “legislative change would support more rapid progress”.
The Long-Term Plan brings in the next iteration of system change through Enhanced Primary Care Networks, new Urgent Treatment Centers and the proliferation of Integrated Care Systems. It is a lack of movement in areas outside of NHS England’s purview which limit its potential. What is more, the Health Committee are sure to focus on ensuring any new legislation doesn’t have the potential to produce road-blocks to reforms outside the NHS.
Transformation will be limited without care reforms
In February 2019 the NHS England and NHS Improvement board meeting set out the case for legislation and are now consulting on their proposals until 25th April. However, precisely because the impetus for legislation comes from NHS England and not Government is significant. As Simon Stevens made clear in front of committee: social care is a matter for Government through the Department of Health and Social Care’s green paper. With care sector proposals outstanding since May 2017, the sector fears it could be playing catch up when it comes to aligning with the NHS.
At a minimum NHS England driven legislation will focus on removing current inefficiencies and workarounds and allow people within the service to focus on delivering care. However, health commentators are keen to point out that social care, prevention and workforce are more than just supplementary. They should sit alongside the plan if system change is to be achieved. Thus, practical implications of legislating for the NHS in isolation could leave the third sector, local authorities and social care out of the conversation. When we see new Integrated Care Systems rolled out avoiding a funding tug of war between local authorities and NHS leaders will be vital for integration.
NHS proposals aim to remove the 2012 Act’s Competition and Markets Authority’s (CMA) duties. The stated ambition being to allow collaboration and integration, so NHS bodies can find innovative solutions to workforce and demand challenges. However, social care on the other hand has seen next steps to address the CMAs analysis of the Care Home market wrapped into the delayed green paper. The complexities of integrating health and social care are obvious, but exacerbated when care reforms are not currently on the table.
Social care, prevention, workforce and money: critical pieces of the puzzle
In transformation there are several pieces of the puzzle scattered in the months and years ahead.
Social care reforms aside, a prevention green paper has been promised by Secretary of State, Matt Hancock, for later this year. Prevention, alongside technology, has been a defining feature of Hancock’s tenure as Heath Secretary. The vision outlined in the “prevention is better than cure” policy paper will need to be built upon and aligned with new NHS structures. If for examples the life science sector wanted to play a key role in prevention, a legislative framework would provide access.
Workforce is another area the long-term plan needs backing. While more about funding than legislation, the Health Foundation, King’s Fund and Nuffield Trust are clear in the title of their report, “a critical moment” approaches. Ruth May, Chief Nursing Officer will have a clear message, particular urgent action required in the retention of the workforce and nursing attrition. The spring of 2019 will therefore be a hugely significant time period for the health service as the Chair of NHS Improvement, Baroness Dido Harding, will deliver the interim NHS Workforce implementation plan.
But be warned: the debate is only just starting…
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